Another view: of progress (or otherwise)

As the end of the year comes into view, it’s traditional to reflect on where we have got to and where we are going.

Given that I’ve spent several months trying to predict where general practice and primary care IT is going – and how we could either save money or work more efficiently as a result – I thought I’d take this opportunity to whinge about how little progress we have made.

Browsers

Browser incompatibility stumps me: I just don’t understand how it is such an issue. At my surgery, we have just been upgraded to Windows 7 with Internet Explorer 8.

I went on a website the other day for a clinical trial for which I’m principal investigator, and it wanted IE 7 – I had to turn on ‘compatibility mode’ to even see it.

Yet today I hear that Microsoft is about to stop security updates for IE 8 and possibly 9 and 10! The new laptops I’ve bought for my kids for Christmas come with Windows 10.

So our ‘upgrade’ is multiple versions behind – and yet it’s too ‘modern’ for one of the sites I need to use.

Hardware

I still walk into practices with a PowerPoint presentation and find they have too old a version to even read modern files. Why can’t we just all have modern, up-to-date kit on our desktops?

Why does the NHS put up with this? I’ve mentioned before that patients of mine who happen to be IT managers just turn over all their company’s equipment every 18 to 36 months.

They just replace it with the latest kit because they are convinced it saves them money in security and support in the long term.

I saw a great story the other day about IBM. It had decided to move its employees off what used to be called IBM PCs to Macs, as it felt the installation, training and support costs were significantly lower.

Compare that to another of my recent experiences. I tried to export some information from my surgery’s Emis clinical software the other day and the computer crashed – out of memory.

Opening it up, I could see that two of the four banks were full – because they only have 2GB memories. I asked our new GP federation IT lead to upgrade my machine. I even offered to pay for it myself.

The answer comes back that the commissioning support unit has only installed the 32 bit version of Windows, which will only take 4GB max! ARGH!!!

When I ask: “Could I have a second monitor – like both my sons and I have at home – so I can have emails and webpages on one monitor and Emis on the other,” it turns out that the graphics card won’t support that.

Passwords

Despite years of people talking about single sign-on, I now have more passwords than ever. In fact, I just can’t keep up and have been forced to give up on everything I was told about security. I’ve started writing them down in a book that I keep in a locked drawer.

When I arrive at work, I need a PIN to get into the car park. Then there is the door code to get into the building and another door code to get a coffee before I head to my room.

Once I’m there, I need my Windows password. My smartcard PIN. My Outlook nhs.net password. My Docman password. My Lexacom password. Just when I think I’m good to go, the first crash happens.

Then, depending on what I am doing, I have to log-on to one of about 30 websites; each of which, of course, has a different password and password policy.

Some lock you out after three attempts. One has a lovely ‘password forgotten’ button that doesn’t ask you all sorts of ridiculous questions, but just emails you a password. Why can’t we use this for everything? Text me a code and I’ll type it! Job done.

Teamworking

Most of the developers of the software that we use seem remarkably unaware that we work in teams. For instance, a receptionist will send me a question or task.

As this is an asynchronous event, it might not get round to reading this for some time. By then, I won’t be able to guarantee that the receptionist will still be working. So, ideally I need to reply back to the team she works in.

Can I do this? No. Every single time, I have to go through a long-winded process of trying to find the team I want to send the message to. The whole messaging systems needs a massive overhaul.

Results

Similarly, as doctors we not only work in teams but need to cross-cover individuals, in order to look after work that should be done by someone who is off stick or otherwise absent. Our systems for doing this are poor at best.

We have developed a system where, when someone remembers to set their ‘out of office’, we can all see their results and action them. Great!

However, the letters system doesn’t integrate. So, at the end of the first week we suddenly realised there was a load of letters that had not been read because they were stuck in one person’s inbox. Integrated partners need to integrate.

The hospital

Pace of change is unbelievably slow. We use Anglia ICE order comms for pathology requesting. We set it up 10+ years ago. We have been asking for radiology to go onto the same system for most of those 10+ years.

The other day, we got a newsletter stating it might happen in 2016. I’m not holding my breath. In the meantime, we continue with a paper system – and all its inefficiencies.

 It is now being nationally recognised that hospitals getting results out to general practice is a huge burden of work for general practice and that it results in a lot of wasted appointments. Yet if we got access to the hospital’s patient administration system, this could be done quite easily.

Similarly, a product called Emis EPR viewer could give any authorised consultant with a smartcard access to the GP record for relatively little money. Instead, millions are being spent on another whole of Cheshire GP record that I’m not convinced is needed or wanted (or secure).

Prescribing

This is becoming my biggest bugbear. Prescribing is the bane of my life, as it’s something I need to do during almost every consultation, yet the warnings issued by the system, and its general stupidity, drives me mad.

First, the warnings. They over-warn to the point at which you ignore them. “Be careful you are prescribing steroids!” “Yes, I know!” “Be careful, this patient is old!” “You know what, I can see that.”

The warnings I really hate are the ones that take the form: “Be careful, reduce dose if eGFR is

Why can’t the system allow me to turn off certain warnings, or disable them for ten times?  Why can’t it be clever about the patient I’m prescribing against, and only warn me about relevant things?

For that matter, why can’t it be clever in general? If I select a drug, why can’t it know the age of the patient and their eGFR and choose the right dose? Why can’t it show me interactions?

Why are most of the drugs I use greyed out? I select Fenbid Gel, as we are meant to. Emis turns it to Ibuprofen, so I press ‘ok’. ScriptSwitch then suggests I’m being naughty and asks me to change to Fenbid Gel – telling the medicines team how much money it has saved, by giving me the drug I asked for in the first place.

Other wishes include a button that lists all the side effects that a patient might have from all the drugs they are on. Then, when some deranged liver tests come back the computer can remind me the Omeprazole that the patient is on is likely to be responsible.

Or when a patient says: “I feel dizzy,” I can say: “Of the 23 medications you are on, 17 have dizziness listed as a side effect.”

Then, there are things that I do all the time, or that my administration team does all the time, that I’d really like to automate.

“Can you synchronise my medication, doctor?” is a dreaded phrase. Some drugs are on one month prescription, some on two months. Some are in packs of 28, some 30.

“I need six tablets of X, 18 of Y, and you need to put Z on two months – and give me four inhalers as I need one for school and one for the gym – and then I’ll be in synch.” ARGH!!!! It’s a very long winded process to do this; when it should be easy.

Save the GP

There are so many ways in which little improvements could be made. Maybe 2016 should be ‘make the life of a GP easier year’. It might even save the NHS! But in the meantime, have a good Christmas. 

Dr Neil Paul Dr Neil Paul is a full time partner at Sandbach GPs; a large (22,000 patient) practice in semi-rural Cheshire. He is also one of the directors of Howbeck Healthcare Ltd. Dr Paul has been involved in primary care IT and health service management for more than ten years in various roles, including PEC member and urgent care lead. In his spare time, he writes medical iPhone software and is a keen photographer.